Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're discussing the evaluation and treatment of male infertility. Joining me is Dr. Peter Kolettis. He's a Professor of Urology at UAB Medicine. Dr. Kolettis, thank you so much for joining us today. I'd like you to speak about the prevalence of infertility, what you see in the trends, and give us a working definition of infertility with males as we know it now.

Peter Kolettis, MD: First of all, thank you for having me. So, the definition of infertility is the inability to conceive after a year of unprotected intercourse. And about 10 to 15% of couples fit that definition. From the male fertility standpoint, that can be defined in many ways, can be defined by a diagnosis such as varicocele or oligospermia, low sperm count. But about half the couples have some male factor contributing to the fertility problem.

Melanie Cole, MS: So, let's talk about the factors that contribute to that fertility issue. What are the causes that we know? What types of issues might a man have that could affect his fertility, whether lifestyle or something else?

Peter Kolettis, MD: In the history, which is important to obtain, one may uncover a history of childhood testicular problems or childhood problems with this spermatic cord, such as undescended testis or spermatic cord torsion. Other things in the history would be prior medical treatment for malignancy with chemotherapy. We know chemotherapy can shut down sperm production temporarily, sometimes permanently. Other drugs, such as testosterone treatment, shuts down sperm production.

And other types of just environmental toxins, particularly smoking. We know that smoking interferes with fertility for some men. So, it's an opportunity to have men stop smoking in this context for their fertility potential, but also for their long-term health.

Melanie Cole, MS: How do you determine what's going on? Tell us a little bit about evaluation and what that's like for the man. But what tests do you do, Dr. Kolettis?

Peter Kolettis, MD: Well, the evaluation for the man is a history where we look for potential causes or contributing factors to fertility. And then, physical examination, focusing on the exam of the testicles and the spermatic cords, size and consistency of the testis, presence or absence of duct structures or any abnormality of the duct structures. And then, testing, the most important test for evaluating fertility is a semen analysis. We do at least one of those. Depending on those results, we do other testing, such as hormone testing or genetic testing. And then, based on putting all those bits of information together, then we come up with a diagnosis and a plan, a treatment plan.

Melanie Cole, MS: Let's talk about some of the treatment plans available. You have many tools in your toolbox. So, what are some of the options for men with infertility? And tell us a little bit about the process.

Peter Kolettis, MD: Well, based on the testing and the evaluation that I described before, the treatment options are-- in a small percentage of cases, there are hormone abnormalities that can be treated. And then, there are procedures to treat infertility, such as vasectomy reversal or correcting other types of duct obstruction, varicocele procedures to correct varicocele, and then procedures to obtain sperm for IVF for a man that has no sperm in the semen.

Melanie Cole, MS: Can you tell us a little bit about those procedures? Are they minimally invasive? Are they done in office? Give us a little bit of a brief overview of the procedures that you do.

Peter Kolettis, MD: Well, the varicocele ligation and vasectomy reversal are done in the operating room. Outpatient procedures, but usually under anesthesia, general anesthesia. They can be done with other types of anesthesia, but I use general anesthesia for them. The sperm retrieval procedures, depending on the complexity, sometimes those can be done on the office. And many times they need to be done in the operating room, depending on the particular clinical situation. So, for example, a man with a known obstruction should have normal sperm production. It should be easy to obtain sperm in the clinic, just percutaneously through the skin.

Other men with a known or suspected disorder or spermatogenesis disorder of sperm production require a more complex procedure in the operating room with an open scrotal procedure, with general anesthetic, and just a much more complicated procedure that involves myself and then the team from the laboratory that will search through the tissue and look for sperm and then process the sperm after that.

Melanie Cole, MS: How are your outcomes, Dr. Kolettis? Speak about the exciting work that you're doing at UAB Medicine and why it's so important when men are looking for fertility specialists that they seek out an expert.

Peter Kolettis, MD: Well, the outcomes depend on several factors including the experience of the surgeon and then the surgical technique. So, the chances for success with the vasectomy reversal depend on surgical technique times and vasectomy, and other details such as the quality of the fluid found at the time of surgery. The chances for finding sperm for those men that have no sperm in the semen and who are looking to do IVF depends on how thoroughly one can sample the testis. And that's a complex procedure that requires a multidisciplinary approach with the team from the lab, as I had mentioned before.

 And then, the reproductive endocrinologist, the fertility gynecologist are part of that team, of course, also. And they evaluate and treat the man's partner and prepare her for IVF and actually conduct the IVF cycle.

Melanie Cole, MS: Wow, it's really amazing what's going on in your field right now. What can a man do to improve the concentration, morphology, and motility of his sperm? Do you have some advice that you give patients every day that other providers can take forward and use to help counsel their patients?

Peter Kolettis, MD: Well, I tell men that anything is good for their health could be good for fertility and certainly is not harmful, again, thinking about long-term health. But we know, as I mentioned before, we know smoking is harmful for fertility. And it's harmful to every other organ system as well. So, smoking cessation can improve a man's fertility potential. Avoiding anything else that's known to be toxic. Illicit drugs, of course, can help a man's fertility. Testosterone treatment disrupts the communication between the pituitary gland and the testis and shuts down sperm production for most men who are using testosterone. So, men of reproductive age really should avoid testosterone treatment until they're done trying to have children.

Melanie Cole, MS: That's great advice. As we wrap up, Dr. Kolettis, what would you like to summarize? What would you like other urologists to take from this segment and learn from your work? Any exciting projects you've got underway? Wrap it all up for us.

Peter Kolettis, MD: Well, the purpose of my seeing a man for fertility is to look for an explanation for the fertility problem, hopefully something that can be treated or corrected or some other condition that might manifest itself as a fertility problem that could affect his health or health of potential offspring. And the best way to do this is with a multidisciplinary approach where the man's partners also evaluated simultaneously, and that gives the couple access to all of the fertility procedures and treatments, the most complex and advance treatment options that are available.

Melanie Cole, MS: Thank you so much, Dr. Kolettis, for joining us and sharing your expertise today on male infertility. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.